Ashley Smith's prison guards in ‘shroud of misdirection and fear’

They watched as blood vessels broke in her face or eyes. They were reduced to counting the number of breaths she took. They saw her nose bleed and her face turn purple.

And yet when guards at the Grand Valley Institute for Women in Kitchener, Ont., tried to rush into Ashley Smith’s segregation cell to cut off the makeshift ligatures around her neck and save her life, they were occasionally physically stopped by superiors or told to pull back and “re-assess,” and if they went in anyway, they were warned, verbally and in writing, that they would face disciplinary hearings for excessive use of force.

Perhaps most cruelly, in an email sent to managers just eight days before Smith’s death, Cindy Berry, then the acting warden at Grand Valley, criticized the guards for “not removing warmth” — ordinary human warmth — from their interactions with Smith. Ms. Berry had reviewed video of an incident where five female guards and a male had gone into Smith’s cell to remove a ligature. In correctional lingo, this constitutes a “use of force” — indeed, physical force was often required to get the ligatures off Smith — and sets in motion the requirement for video and a great whack of paperwork.

“After the use of force,” Ms. Berry wrote her correctional managers on Oct. 11, 2007, “various [guards] can be seen interacting/chatting/talking to Ashley and not removing warmth. … Almost all interventions include various [guards] talking during the use of force … they are all giving direction and/or pleading with Ashley.”

This was the agonizing high-wire dance of the days and weeks before the Oct. 19, 2007 death of the 19-year-old Smith.

It led to some of those who worked with her “being terrified of what [she] was going to do and didn’t know what we were supposed to do.” One investigator later called the atmosphere for guards a “shroud of misdirection and fear.”

The stark glimpse of Smith’s last terrible days in a Canadian prison and the Kafkaesque miasma of confusion created for staff by prison and Correctional Service of Canada management is detailed in a Sept. 7 Public Service Labor Relations Board decision publicly released late last month.

(An Ottawa colleague was kind enough to alert me to the decision, and I thank her for it.) John Steeves was adjudicating the suspension of a middle manager at the prison named Michelle Bridgen, who had been disciplined after Smith’s death, as one of several managers who gave guards “explicit direction” that they weren’t to enter Smith’s cell “as long as she was breathing.”

Ms. Bridgen had been docked 20 days’ pay, but that was cut in half by Mr. Steeves because while he found she had made mistakes, she was “being held culpable for actions that higher management” directed her to do.

Smith entered the youth correctional system in her native New Brunswick for throwing apples and pulling fire alarms.

But while in the youth system, her behavioural and mental-health issues escalated such that she incurred so many “institutional charges” that when she turned 18, she was transferred to the federal system as an adult to serve out her sentence.

But she was so hard to handle — she “tied up” as often as eight times a day, secreted pieces of glass on her body to fashion an endless supply of ligatures, and would sometimes become confrontational with guards — that Smith was a sponge for institutional resources.

In less than a year in the federal system, she was transferred an astonishing 17 times — often for the convenience of the prison and for no discernible benefit to Smith.

For all its dry language and confusing reference to other reports — chiefly an internal board of investigation ordered by the CSC after Smith’s death — Mr. Steeves’ 80-page decision contains shocking details about the Byzantine processes of the correctional bureaucracy.

Among them:

• Deputy Warden Joanna Pauline reportedly believed, and according to one guard who testified may have told Ms. Bridgen, “that this inmate Smith thing was all about auto-eroticism.”

• According to the internal board investigation, which Mr. Steeves quoted at length, about a week before her death, an unidentified prison psychologist took Smith to an interview room and “made some cards” with Smith, who loved to draw and write.

This seems to have been held up as an example of how Smith was still getting human contact.

Alas, the report noted, the game took place “with Ashley Smith handcuffed at the back, so her actual participation was limited.”

• While guards, those who worked most closely with her at Grand Valley, expressed concern to management “over and over again,” as one of them put it, “that this [Smith’s ligature use] was a mental-health issue,” their superiors replied “it was a behavioural issue.” Guards believed Smith “needed mental-health intervention” and felt ill-equipped because they weren’t psychiatric nurses.

As one guard told the internal investigator, “It was getting very scary. She was viewing [Smith] through the back window and timing her breaths — 10-15 per minute. Haven’t seen her breathe in over a minute. We need to go in but Michelle Bridgen said no.” Another said that “managers down-played [Smith’s] psychiatric well-being.”

• A few days before Smith’s death, regional management was so concerned about the rise in use-of-force reports generated by the guards constantly racing into her cell to cut off the ligatures that they dispatched someone to conduct a special training session.

Three witnesses testified the man’s message was that staff “were going in too soon, too many times.” One believed he also said that “they had one minute [to act] if inmate Smith quits breathing,” while another said he predicted she “will die by misadventure.”

It was getting very scary

Finally, as the internal investigator wrote in her Feb. 25, 2008 report, the most startling contradiction was that while everyone knew Ashley Smith had slivers of glass and ligatures hidden in her cell or on her body, there was a “repeated lack of searching,” either of her or her cell to remove them.

This failure, the investigator concluded, “especially after she was deemed a high suicide risk” in October that year, allowed her to continue tying up and “eventually led to her death.”

The oft-delayed coroner’s inquest into Ashley Smith’s death is slated to begin early in the new year.